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Health Center:
Memorial Hospital
Pharmacy:
Trapp Pharmacy (#1)
Capture Date :
To:
Fetching results...
Health
Center
Pharmacy
ShipTo
Claim
Type
RX
Number
Member ID
Fill
Fill Date
Adjud
Date
Captured
Date
NDC
Drug
Name
Strength
Form
Pkg
Size
QTY
Disp
Curr
QTY
% of
Claim
Status
Status
Date
Order
Wholesaler
Invoice
False
4289833
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000780532
MR00038013
03
08/16/2021
08/16/2021
08/17/2021
69097031987
BUDESONIDE 0.5 MG/2 ML SUSP
0.5 MG/2ML
AMPUL-NEB.
60
60
60
100.00000
Replenished
1001904997
3064847322
False
4585066
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000780532
MR00038013
04
09/23/2021
09/23/2021
09/24/2021
69097031987
BUDESONIDE 0.5 MG/2 ML SUSP
0.5 MG/2ML
AMPUL-NEB.
60
60
60
100.00000
Replenished
1001927749
3068767552
False
5155227
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000780532
MR00038013
05
12/10/2021
12/10/2021
12/11/2021
69097031987
BUDESONIDE 0.5 MG/2 ML SUSP
0.5 MG/2ML
AMPUL-NEB.
60
60
60
100.00000
Replenished
1001972080
3076588674
False
5405134
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000780532
MR00038013
06
01/13/2022
01/13/2022
01/14/2022
69097031987
BUDESONIDE 0.5 MG/2 ML SUSP
0.5 MG/2ML
AMPUL-NEB.
60
60
60
100.00000
Replenished
1001989515
3080235784
False
5672698
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000780532
MR00038013
07
02/17/2022
02/17/2022
02/18/2022
69097031987
BUDESONIDE 0.5 MG/2 ML SUSP
0.5 MG/2ML
AMPUL-NEB.
60
60
60
100.00000
Replenished
1002008101
3084006370
False
6185902
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000789841
MR00038013
00
04/26/2022
04/26/2022
04/27/2022
69097031987
BUDESONIDE 0.5 MG/2 ML SUSP
0.5 MG/2ML
AMPUL-NEB.
60
60
60
100.00000
Replenished
1002043399
3091212807
False
6487308
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000790747
MR00038013
00
06/07/2022
06/07/2022
06/08/2022
69097031987
BUDESONIDE 0.5 MG/2 ML SUSP
0.5 MG/2ML
AMPUL-NEB.
60
60
60
100.00000
Replenished
1002064768
3095648625
False
6782465
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000791246
MR00038013
00
07/01/2022
07/01/2022
07/02/2022
69097031987
BUDESONIDE 0.5 MG/2 ML SUSP
0.5 MG/2ML
AMPUL-NEB.
60
60
60
100.00000
Replenished
1002075849
3098184654